| Procedural | Drug-related |
| Wrong-sided block | Overdose of midazolam during conscious sedation |
| Retained throat swab | Wrongly prepared, high - risk injectable medication |
| Retained CVC wire | Maladministration of potassium - containing solutions |
| Misplaced NG/OG tube | Wrong route of administration of oral treatment |
| Misidentification of patient | IV administration of epidural administration |
| Unrecognised oesophageal intubation | Opioid overdose in opioid naïve patient |
| Air embolism | Wrong gas administration |
| Maternal death from PPH post-elective LSCS | Transfusion of ABO incompatible blood |
Never Events
Never Events
Resources
- A never event is a:
Serious, largely preventable patient safety incident that shouldn't have occurred if the available preventative measures were implemented
- Immediate restitution of harm
- Reporting the incident through risk management/clinical incident system
- Report the incident via the CCG and NHS England
- Communication with patient (/carers/relatives) in line with 'Being Open' policy
- Undertaking a root cause analysis
- Implementing and sharing lessons learned from RCA